Hematopoietic Cell Transplantation for Solid Tumors of Childhood (ARCHIVED)

Policy ID: S-221-016

Section: Surgery

Effective Date: January 01, 2020

Revised Date: October 31, 2022

Revision Effective Date: January 01, 2023

Last Reviewed: November 29, 2022

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective January 01, 2023. Click the Archive tab above for more information.

Policy ID: S-221-015

Section: Surgery

Effective Date: January 01, 2020

Revised Date: July 12, 2021

Revision Effective Date: September 06, 2021

Last Reviewed: July 21, 2022

Archived Date: December 31, 2022

Applies To: Commercial and Medicaid Expansion

Description

HCT involves the intravenous (IV) infusion of allogeneic (donor) or autologous stem cells to reestablish hematopoietic function in individuals whose bone marrow or immune system is damaged or defective. They can be harvested from bone marrow, peripheral blood, or umbilical cord blood and placenta shortly after delivery of neonates.

Solid tumors of childhood arise from mesodermal, ectodermal, and endodermal cells of origin. Examples of some common solid tumors of childhood are neuroblastoma, Ewing sarcoma/Ewing sarcoma family of tumors (ESFT), Wilms tumor, rhabdomyosarcoma, osteosarcoma, and retinoblastoma.

Criteria

Autologous HCT may be considered medically necessary for ANY ONE the following indications:

Initial treatment of high-risk neuroblastoma:
- High-risk neuroblastoma is characterized by (not an all-inclusive list):
  - Age older than one (1) year; and
  - Disseminated disease; and
  - MYCN oncogene amplification; and
  - Unfavorable histopathologic findings; or
Recurrent or refractory neuroblastoma; or
Initial treatment of high-risk Ewing’s sarcoma; or
Recurrent or refractory Ewing's sarcoma; or
Metastatic retinoblastoma.

Autologous HCT is considered experimental/investigational and, therefore non-covered because the safety/and/or effectiveness of this service cannot be established cannot be established by the available published peer-reviewed literature for the following conditions:

Initial treatment of low- or intermediate-risk neuroblastoma; or
Initial treatment of low- or intermediate-risk Ewing’s sarcoma; or
Rhabdomyosarcoma; or
Wilms tumor; or
Osteosarcoma; or
Retinoblastoma without metastasis.

Procedure Codes

38204

38205

38206

38208

38209

38210

38211

38212

38213

38214

38215

38232

38241

S2150

A maximum of three (3) tandem autologous HCT’s may be considered medically necessary for treatment of high-risk neuroblastoma when ALL the following have been met:

Individual does not have a concurrent condition/disease, which would seriously compromise the chance of attaining a durable complete remission with this therapy; and
Individual has stem cell product that meets infusion criteria of viability and neuroblastoma stem cell contamination (less than one (1) neuroblastoma cell per 100,000 peripheral blood progenitor cells or less than 10% morphological evidence bone marrow involvement) prior to transplant.

Tandem autologous HCT not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

38204

38205

38206

38208

38209

38210

38211

38212

38213

38214

38215

38232

38241

S2150

Allogeneic (myeloablative or nonmyeloablative) HCT is considered experimental/investigational and, therefore, non-covered for treatment of pediatric solid tumors. There is inadequate evidence in peer-reviewed literature demonstrating the effectiveness of allogeneic cell transplantation for the treatment of pediatric solid tumors.

Salvage allogeneic HCT for the treatment of pediatric solid tumors that relapse after autologous HCT or fail to respond is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

38230

38240

38242

S2150

Diagnosis Codes

Covered Diagnosis Codes

C40.00

C40.01

C40.02

C40.10

C40.11

C40.12

C40.20

C40.21

C40.22

C40.30

C40.31

C40.32

C40.80

C40.81

C40.82

C40.90

C40.91

C40.92

C41.0

C41.1

C41.2

C41.3

C41.4

C41.9

C74.00

C74.01

C74.02

C74.10

C74.11

C74.12

C74.90

C74.91

C74.92

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network

Bone Cancer (v.1.2022) – 2021

Osteosarcoma – The safety and efficacy of HDT/HCT in patients with locally advanced, metastatic, or relapsed osteosarcoma have also been evaluated. In the Italian Sarcoma Group study, treatment with carboplatin and etoposide was followed by stem cell rescue, combined with surgery-induced complete response in chemosensitive disease. Transplant-related mortality was 3.1%. The 3-year OS and DFS rates were 20% and 12%, respectively. The efficacy of this approach in patients with high-risk disease is yet to be determined in prospective randomized studies.
Ewing Sarcoma – High-dose therapy followed by stem cell transplant (HDT/SCT) has been evaluated in [individuals] with localized as well as metastatic disease. HDT/SCT has been associated with potential survival benefit in [individuals] with non-metastatic disease. However, studies that have evaluated HDT/SCT in [individuals] with primary metastatic disease have shown conflicting results.
Rhabdomyosarcoma – HCT not addressed.

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Reformatting to HMK policy. HMK has additional criteria under tandem

12-17-2019 no change in Criteria, changes in Wording

Internal Medical Policy Committee 03-16-2020 Coding update only.

Internal Medical Policy Committee 03-17-2021 Revision of layout of policy;

Removal of codes 38220, 38221, & 38222; and
Removal of multiple procedure codes; and
Added indications.

Internal Medical Policy Committee 07-22-2021 Coding update

Removal of procedure codes 86812, 86813, 86816, 86817, 86821.

Internal Medical Policy Committee 7-21-2022 Annual Review - no changes in criteria

Internal Medical Policy Committee 11-29-2022 Archiving Policy- Effective January 01, 2023

Please refer to policy S-273 Hematopoietic Cell Transplantation: Solid Tumors

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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Medical Policies Quick Search

Hematopoietic Cell Transplantation for Solid Tumors of Childhood (ARCHIVED)

This policy has been Archived effective January 01, 2023. Click the Archive tab above for more information.

Description

Criteria

Procedure Codes

Procedure Codes

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer